Chest tube after lung resection—a small change to a great benefit

Yun and colleagues (1) present a manuscript on a modified method for chest drain insertion after thoracoscopic or robotic lung resection surgery.

The authors designed and conducted a prospective trial that randomized patients to conventional and modified chest drain placement techniques. Traditionally, chest drains are placed after lung resection surgery through the incision used for the camera port, which will put the intercostal incision and the skin incision at the same level. When performing open surgery, a new incision is done at the end of the procedure and the drain put through, usually also at the same level regarding skin and intercostal incisions.

The modified technique consisted of passing the drain to the upper intercostal space, in the camera port, at the end of the procedure instead of the conventional technique of simply pass the drain through the incision created for the camera port, as described by Yang et al. (2).

The principle of dislocating the skin incision and the intercostal incision has been previously described (3). Still, the authors proposed a technique that allows keeping the skin incision as described for thoracoscopic techniques.

Other techniques to avoid complications, such as fluid or air passage through the drain wound are described, such as modified sutures (4) or the use of barbed sutures (5,6), but this is out of the scope of the manuscript presented by Yun et al. (1).

Managing the drain wound is vital for good outcomes and avoiding infectious complications, and multiple options are available. In this paper, 199 patients were randomized and the modified chest tube placement proposed by the authors proved safe and had better clinical efficacy than the conventional technique. The reduction of postoperative peritubular leakage of pleural fluid (39.6% vs. 18.4%, P=0.007) resulted in better wound recovery. Air leak or entry was also reduced (14.9% vs. 5.1%, P=0.022). The authors also evaluated the number of dressing changes which was reduced in the modified technique group (5.02±2.30 vs. 3.48±0.94, P>0.001).

Although the sample size was small, the benefit was not verified in less complex procedures, such as wedge resections. The benefit was statistically significant in patients who underwent lobectomy or segmentectomy (P>0.05). However, we firmly believe that the benefit would be visible in a larger sample size of wedge resections and motivate further studies.

The authors provided a well-designed study and a well-structured statistical analysis and manuscript. We point to the sample size as a limitation and believe that further studies will consolidate the authors’ findings.

Therefore, this modified strategy should be popularized, especially in patients undergoing pulmonary lobectomy or segmentectomy.

The possible economic impact of a more efficient management of the chest drain would be remarkable. Changing the drain placement technique would add no extra costs, and one hospitalization day in the ward spared would be around £500 considering data from the NHS.

How do we incorporate the authors’ findings into clinical practice?

We live in times of great worldwide economic recession, and healthcare struggles to thrive in times where every cent matters. The rising costs of novel therapies and technologies make adopting innovation difficult for many countries.

Simple and cost-effective, easily reproducible techniques are rarely studied, even though they have the potential for a significant positive impact worldwide. In that regard, we congratulate the authors for their work.

The authors of the manuscript we are commenting on (1) provide a technique that is easily reproducible and cost-effective. It includes a change in the simple gesture of drain placement, without any increase in the costs or duration of the surgical procedure, with the potential to avoid complications of the drain wound.

Any thoracic surgeon can adopt this technique and see for themselves the positive impact. Scientific curiosity and willingness to improve should drive surgeons worldwide to provide better care within the existing resources. The possibility of being better is in everyone’s hands.

We believe that further studies regarding this subject should be considered as a vital part of further investigation in a new era of enhanced recovery after surgery. The role of chest drain is of vital importance and its use should be kept to the minimum possible. By adopting a proper technique to avoid drain-related complications, the results of an enhanced recovery after surgery program can be even better.

In conclusion, this article may provide valuable data to improve the everyday clinical practice of any thoracic surgery center by providing a low-cost technique that may reduce the incidence of cutaneous complications.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Clinical Trials Review. The article has undergone external peer review.

Peer Review File: Available at https://actr.amegroups.com/article/view/10.21037/actr-23-27/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://actr.amegroups.com/article/view/10.21037/actr-23-27/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Yun T, Zhang Y, Liu A, et al. Randomized Trial of Modified Chest Tube Placement vs Routine Placement After Lung Resection. Ann Thorac Surg 2023;116:1013-9. [Crossref] [PubMed]
2. Yang SM, Kuo SW. Incision for Uniportal VATS: Above the Rib or Intercostal Space? Ann Thorac Surg 2016;101:2020-1. [Crossref] [PubMed]
3. Son BS, Park JM, Seok JP, et al. Modified incision and closure techniques for single-incision thoracoscopic lobectomy. Ann Thorac Surg 2015;99:349-51. [Crossref] [PubMed]
4. Imamura Y, Watanabe H, Hiramatsu Y, et al. Knotless suture and hydrocolloid method improves chest drain wound complication. Asian Cardiovasc Thorac Ann 2022;30:807-12. [Crossref] [PubMed]
5. Kim KS. Barbed suture material technique for wound closure and concomitant tube placement in uniportal VATS for pneumothorax. J Thorac Dis 2017;9:1265-72. [Crossref] [PubMed]
6. Kim MS, Shin S, Kim HK, et al. Feasibility and Safety of a New Chest Drain Wound Closure Method with Knotless Sutures. Korean J Thorac Cardiovasc Surg 2018;51:260-5. [Crossref] [PubMed]